Liberty 2000 Limited. CURRENT STATUS: 27-Jun-13

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1 Liberty 2000 Limited CURRENT STATUS: The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Certification audit conducted against the Health and Disability Services NZS8134.1:2008; NZS8134.2:2008 & NZS8134.3:2008 on the audit date(s) specified. GENERAL OVERVIEW Kintala Lodge Rest Home continues to provide specialist dementia care services to a maximum 30 residents. On the days of audit there are 21 residents. All residents except one are over the age of 65 years. There is one resident whose care is funded by the Accident Compensation Commission. The general manager reports there have been no sentinel events, no coroners inquests or police investigations since the previous audit. There have been no complaints to the Office of the Health and Disability Commissioner but a complaint submitted by a family to the Ministry Of Health (MoH) in early 2013 was investigated by Ministry staff via an unannounced inspection on 21 March. The service has implemented the five corrective actions identified as a result of that audit. Two registered medical practitioners who were interviewed by telephone spoke favourably about the care provided. Two visiting district health board (DHB) clinicians declined to be interviewed. An advocate from the Nationwide Health and Disability Advocacy Services was contacted by telephone. This person stated that there had only been staff education services provided (not advocacy services) by their service, but that two visits to the facility had not identified any obvious concerns. This certification audit found no areas for improvement. AUDIT SUMMARY AS AT 27-JUN-13 have been assessed and summarised below: Key Indicator Description Definition Includes commendable elements above the required levels of performance All standards service fully with some standards exceeded

2 Indicator Description Definition No short falls service fully Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity A number of shortfalls that require specific action to address Major shortfalls, significant action is needed to achieve the required levels of performance Some standards service partially and of low risk Some standards service partially and of medium or high risk and/or un and of low risk Some standards service un and of moderate or high risk Consumer Rights Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs. Organisational Management Includes 9 standards that support an outcome where consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner. Continuum of Service Delivery Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation.

3 Safe and Appropriate Environment Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities. Restraint Minimisation and Safe Practice Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. Infection Prevention and Control Includes 6 standards that support an outcome which minimises the risk of infection to consumers, service providers and visitors. Infection control policies and procedures are practical, safe and appropriate for the type of service provided and reflect current accepted good practice and legislative requirements. The organisation provides relevant education on infection control to all service providers and consumers. Surveillance for infection is carried out as specified in the infection control programme. AUDIT RESULTS AS AT 27-JUN-13 Consumer Rights Staff openly discuss and demonstrate a knowledge of the Health and Disability Commissioner's (HDC) Code of Health and Disability Services Consumers' Rights (the Code) and are able to provide evidence of this in their daily practice. Residents and family members are informed of rights on admission, both verbally and in writing. Copies of the Code are clearly placed throughout the facility as on-going reminders. Family members are informed about any clinical or situational change of the resident. The cultural, spiritual and ethnic values are assessed on admission and assist staff in ensuring that suitable and appropriate care is provided in line with the individual's beliefs. Staff demonstrate awareness of the need to celebrate the differences of various cultures and beliefs and are responsive to the needs of the residents. Residents are provided with respectful and dignified care by a consistent team of suitably qualified long term staff members.

4 The service has an effective and well communicated complaints management system which includes a register to log all written and verbal complaints There is evidence that staff and families are informed about the complaints process and that when complaints are raised these are managed efficiently and effectively to reach resolution. Organisational Management There is an established and effective quality and risk management system. All aspects of service delivery are clearly described in policies and procedures. Policies demonstrate best known clinical practice and are reviewed regularly. Service marketing literature, governance documents and policies define the scope, direction and goals of the service. There is a current business plan, continuous improvement plans and day to day documents which describe and demonstrate how the monitoring of service delivery and the reporting of progress towards goals occurs. Quality data (e.g., incident/accidents, complaints, infections, audit outcomes and relative feedback) is collected and analysed to improve service delivery. Quality data is analysed and results are communicated to staff and key stakeholders (e.g., the governing body, DHB funding and planning and other service providers as appropriate). There is a full time employed general manager, who is responsible for human resources, business systems, resource procurement and oversight of day to day operations; and a full time employed registered nurse (RN) second in charge, who oversees residents' care and delivery of clinical services. The RN/second in charge has been with the service since 2008 and an additional RN has been recently employed. The adverse event reporting system is a planned and co-ordinated process. Staff clearly and reliably report and/or document adverse, unplanned or untoward events. There is evidence that all residents' falls, skin tears, bruises, challenging behaviour, medicine errors and other incidents are reported. Families and other affected parties (e.g., general practitioners) confirm they are appropriately notified of incidents, in a timely manner. The human resources management system provides for timely employment of suitable staff and on-going staff training and development. There is a clearly documented rationale for determining staff levels and skill mix in order to provide safe service delivery. Rosters and interviews demonstrate that staff are allocated according to contract requirements. A RN is available on site for eight hours a day, five days a week and available on call 24 hours a day, seven days a week. The second RN works regular afternoon shifts. There is an appropriate number of suitably qualified and skilled care staff and auxiliary staff on site for all shifts. The overall number of staff is small (18 inclusive of the manager) and there is a low staff turnover. All staff are informed about systems, policy and processes and report they are well supported in terms of professional development.

5 The systems for managing consumer information are effective and meet the requirements of the standard. Continuum of Service Delivery Residents receive care in a timely manner that is planned and coordinated by a registered nurse (RN) using suitable assessment tools for a variety of clinical, behavioural and cultural situations. Care plans are developed from information acquired from family members, medical assessments and the initial NASC assessments. Care plans are individualised and detailed with relevant information. Interventions reflect the resident's input. Activities are undertaken by a qualified diversional therapist. The programme is varied and suits the needs of the residents. This is reviewed annually. Residents are encouraged to be active and move freely in a non-restrained manner. The environment has been purpose built to suit this activity. Medicines are managed safely and meet all legislative requirements. Residents did not appear sedated and are able to have choice over taking medications.<cr> Each resident's nutritional and fluid requirements are provided for. Food is available 24 hours a day and residents' likes, dislikes, special diets and eating patterns/needs are known and catered for. The service has recently implemented additional quality improvements in regards to monitoring and managing residents with weight loss. Meals are served at times that suit individual residents' daily patterns. There is a four week, summer/winter rotating menu which has recently been reviewed and approved by a registered dietician. Safe and Appropriate Environment The building is in good repair and has a current building warrant of fitness. The service has clearly documented emergency preparedness plans and the contingencies in place are maintained to allow for service continuity in the event of a natural disaster or civil emergency. All but one staff member holds a current first aid certificates. The fire evacuation scheme is approved by NZ Fire services and fire suppression systems are tested regularly. Cleaning and laundry services meet the requirements of the standard. Facility improvements are on-going. Restraint Minimisation and Safe Practice The service has a clearly described restraint minimisation and safe practice policy and staff demonstrate a thorough understanding about the requirements of the standard. There is evidence that restraint use is minimized and only used for safety reasons when absolutely necessary. The only restraints approved for use are bedrails and a safety seat. On the days of audit there are two residents authorised for restraint use for safety reasons (e.g., one who requires bedrails when in bed at night and one who benefits from use of the safe seat at times). Processes for assessment, approval, consent, evaluation and review of these restraint interventions comply with the requirements of the standard. Services are provided in a discreetly secure locked environment which is appropriate and necessary for resident safety.

6 Residents have access to external areas which are secure and safe. Staff are provided with regular on-going education in restraint minimisation and managing challenging behaviour. Infection Prevention and Control The infection control practices in Kintala Lodge are guided by an internally produced Infection Control Manual. There is a functional relationship between Kintala Lodge and the Waikato DHB Population Health if there is an outbreak. They have a relationship with Peer groups - Waikato infection control peer group and restraint and the infection control, standards and certification peer group. The service is able to demonstrate a managed environment that minimises the risk of infection for residents. The ability to isolate and minimise potential risk was evident. Reporting, monitoring and evaluation of outcomes is a regular and on-going process. The RN works in supportive role with the manager for best practice outcomes. The incidents of infection are entered into the Healthcare Help Benchmarking statistics website which seven dementia facilities submit their data.